Sexual Violence and Women from West and Central

Refugees from African countries are the major focus of Australia’s current Humanitarian program comprising around 70% of all refugee and humanitarian entrants in 2004-05. This MOROCCO TUNISIA trend will continue with Africa identified as a regional priority of the Humanitarian ALGERIA WESTERN LIBYA Program. The majority of are SAHARA from southern Sudan, however there are MAURITANIA increasing numbers coming from other MALI NIGER

African countries including Liberia, SENEGAL CHAD ERITREA GAMBIA GUINEA BURKINA SUDAN Sierra Leone, Burundi, Rwanda and the BESSAU DJIBOUTI GUINEA BENIN NIGERIA SOMALIA Democratic Republic of Congo (DRC). SIERRA LEONE COTE TOGO D IVOIRE CENTRAL ETHIOPIA Many of these recent arrivals have LIBERIA GHANA AFRICAN REPUBLIC endured prolonged periods under harsh CAMEROON EQUATORIAL GUINEA UGANDA conditions in refugee camps, or among CONGO GABON RWANDA KENYA the local population in neighboring DEMOCRATIC BURUNDI REPUBLIC countries such as Guinea, Uganda, Kenya Cabinda (ANGOLA) OF CONGO and Tanzania. As new and emerging TANZANIA communities, they are small in number ANGOLA MALAWI and have few support networks to assist ZAMBIA

MOZAMBIQUE them. Of special concern among the new ZIMBABWE arrivals are women, many of whom have NAMIBIA MADAGASCAR BOTSWANA been particularly affected by war-related (Walvis Bay) violence. SWAZILAND

LESOTHO In addition to persecution and serious SOUTH AFRICA human rights violations which affect all refugees, women are often subjected to sexual violence including , torture assume new roles and responsibilities long after it has occurred. Despite and mutilation, and sexual slavery. as they face the burden of caring for their resilience, feelings of shame, guilt, Such violence is prevalent during armed their children without the support of distrust, and low self-esteem conflict but also occurs frequently in traditional extended family. Their children may prevent women from seeking help camps and other places where women may have different biological fathers and or offering disclosure. Women may have seek refuge. Persistent insecurity and women may be caring for the children had little access to physical health care deprivation caused by their forced of family members who were killed or and culturally may have no concept of displacement mean that women have disappeared. In addition, the pressures seeking help for psychological problems. been unable, or afraid, to obtain medical, of resettlement, having to adapt to a new Through sensitive and appropriate psychological and . language, culture and way of life, can be interventions, GPs and other health stressful and deter women from seeking professionals in Australia can contribute Many women enter Australia under the assistance. The trauma of sexual violence to the health and well-being of these Woman At Risk program and are often can seriously impact on the physical women and support them in the process the sole head of household. They must and of refugee survivors of recovery.

Woman At Risk (Visa Subclass 204) Australia introduced the Woman at Risk visa class in 1989 in recognition of the priority given by UNHCR to the protection of refugee women in particularly vulnerable situations. This program identifies women who are extremely vulnerable, without family protection and in danger of victimization and abuse. About 5,000 Woman at Risk visas have been granted since 1989 and the government currently reserves around 10.5% of its refugee quota. Recent intake from Africa includes women from Liberia, Burundi, Sierra Leone, Congo and Sudan. It is important to note that women who have experienced similar circumstances may also enter under other humanitarian and migrant categories.

-  - War and Sexual Violence in Liberian arrivals fled the civil war in protect women have been destroyed West and Central Africa Liberia in the nineties seeking refuge and with them the norms that would in Côte d’Ivoire. In 2002, rebels from prevent sexual violence against women. Civil wars have ravaged many countries Liberia and Côte d’Ivoire attacked the High levels of frustration and insecurity in Africa in recent decades. Though the region where the refugees were living and associated with the loss of male causes and nature of the conflicts are they were forced to flee again, this time traditional roles contributes to domestic complex, the fighting in Liberia, Sierra to Guinea. abuse against women. Leone, Côte d’Ivoire, Sudan, Rwanda, Burundi and the Congo (DRC, formerly Violations targeted against civilians were Violence against women is Zaire) have all been characterized by perpetrated by government and resistance defined by the UN Declaration ethnic violence, systematic human rights forces and included killings, arbitrary on the Elimination of Violence abuses, extensive destruction, poverty arrest and torture. Rape and other forms and massive flows of refugees. Many of sexual violence against girls and women against Women, adopted by refugees have had to flee persecution reached epidemic proportions in all of the General Assembly on 20 continuously. For example, recent these countries. Sexual violence included December 1993, as “any act gang rape, abductions for sexual slavery, of gender-based violence that Liberia: Sexual violence is beatings and mutilation. Even the elderly results in, or is likely to result in, reported to have affected up to and the very young were not spared. The physical, sexual or psychological 40% of women during the 14 year widespread use of child soldiers included harm or suffering to women, civil war. girls who were subjected to including threats of such acts, and also forced to commit violence, often coercion or arbitrary deprivation Rwanda: An estimated half a under the influence of drugs. million women were raped during of liberty, whether occurring in the 1994 genocide. Seeking Refuge: No Protection public or in private life”. It is a form of gender-based violence and Sierra Leone: Up to 50% of all Women continued to face security risks includes sexual violence. women were subjected to sexual in refugee camps. The breakdown of violence, including rape, torture traditional protection mechanisms, a Sexual violence includes sexual and sexual slavery. climate of impunity, and stigmatization exploitation and sexual abuse. It of the victim contributed to high rates refers to any act, attempt, or threat Burundi: A 1999 survey of rape and sexual harassment. Despite of a sexual nature that results, estimated that one in four food insecurity, the fear of attack would or is likely to result in, physical, Burundian refugee women in prevent women from undertaking psychological and emotional northern Tanzania had been a normal activities to supply food, water harm. Sexual violence is a form of victim of rape or serious sexual and firewood for their families. Many gender based violence. harassment. were forced into sex to obtain food http://www.irinnews.org/ rations or other supplies. Levels of http://www.irinnews.org/ webspecials/GBV/default.asp domestic violence in camps are also high webspecials/GBV/Definitions.asp as family and social structures which

Country Life Under 5 Maternal Lifetime Total Specific Health Concerns: Expentacy Mortality Mortality Rate Risk of Fertility at Birth Rate - Pregnancy Maternal Rate Refugee women who have suffered (years) (b) related Death (d) traumatic events such as sexual (a) (2003) (c) (2000) (2003) violence have particular physical and (2003) (2000) psychological health needs that require special attention. Most will have had Liberia 41 235 760 1 in 16 6.8 poor access to healthcare prior to arrival Sierra Leone 34 284 2000 1 in 6 6.5 in Australia. Pre-arrival health screening Burundi 41 190 1000 1 in 12 6.8 is not comprehensive, its purpose being DR Congo 42 205 990 1 in 13 6.7 to prevent possible public health risks. An awareness that women may have been Rwanda 39 203 1400 1 in 10 5.7 exposed to sexual violence will assist in Sudan 56 93 590 1 in 30 4.3 early identification and intervention. Australia 79 6 8 1 in 5800 1.7 A sensitively conducted health care consultation can also make a significant contribution to psychological recovery, Source : UNICEF http://www.unicef.org/statistics/index_countrystats.html (a) Years a newborn is expected to live on prevailing patterns of mortality. providing reassurance to those who feel (b) Per 1000 live births. they have been irreparably harmed and (c) Per 100 000 live births. help to re-establish their sense of self- (d) Average number of live children born to a woman during her lifetime. worth.

-  - Specific health issues related to sexual violence include: Acute Injuries and Gynaecological Problems • damage to cervix, upper vagina, vulva, anus and rectum, urethra, uterus and oral cavities, fistula and other internal injuries • broken bones: untreated because of inability to access health services • soft tissue damage • amenorrhoea/dysfunctional uterine bleeding, sexual dysfunction Sexually Transmitted and HIV AIDS • increased risk due to exposure to high rates of sexual violence and lack of access to appropriate testing and services in the aftermath of rape and sexual violence • low level of awareness of how diseases are contracted and spread; lack of knowledge/access to condoms for prevention, limited ability to negotiate safe sex • STI’s may include ,Gonorrhoea, • and C are more common as a result of rape, in-utero transmission, unsterilised and reused medical equipment • all refugees over 15 will have undergone HIV testing in pre-arrival health screening, however this process may fail to detect a recent Nutritional Deficiencies • common to women as a result of prolonged deprivation in refugee camps/settings • inadequate access to clean water and nutritious food may cause long-term vitamin and mineral deficiency • menstruation and breastfeeding both contribute to nutritional needs. May require iron and folate supplementation • high rate of intestinal parasites among some refugee populations may lead to • diseases endemic to Africa, eg and schistosomiasis, can contribute to nutritional deficiency and chronic ill-health • micro-nutrient deficiency disorders eg vitamin D deficiency • diet-related disorders eg non- dependent mellitis • eating disorders as a result of past trauma and torture eg poor appetite, anorexia, excess consumption Pregnancy and Childbirth Complications • pregnancy may be the result of rape with associated feelings of shame and rejection • high fertility rates increase susceptibility to complications, nutritional deficiency, low birth weights • scarce and often inadequate health services in camps or in communities where refugees have lived including maternal and neonatal care, unattended births, unsafe abortions, unsterilised equipment, poor sanitation, high infant mortality rates may create regarding pregnancy and birth, eg in DRC, 42,000 women died in childbirth in 2001 (IRIN) • effects of Female Genital Mutilation (FGM), see below • aspects of ante-natal, labour and post-natal care (eg examinations, medical instruments) may invoke memories of past torture or assault • may lack knowledge of family planning and access to contraception • a lack of familiarity with hospital settings and procedures may cause confusion and anxiety Psychosomatic and Psychological Effects • somatic symptoms such as back pain, migraines, fatigue, general muscular aches and pains, fibromyalgia, chronic pelvic pain • psychological symptoms may include Post Traumatic Stress Disorder (PTSD), anxiety, depression • psychological problems may include low self-esteem, shame, social isolation • marital and relationship problems, including feelings of rejection, guilt, anger and blame. Male family members may feel guilt over their failure to protect their female relatives • no, or limited concept of, psychological illness, or talking and disclosure as a way of improving health Female Genital Mutilation (FGM) (also known as female circumcision, traditional female surgery or female cutting) • defined by WHO as: ‘all procedures involving partial or total removal of the female external genitalia or other injury to the female genital organs whether for cultural or other non-therapeutic reasons’ • practiced in different forms in many African countries including Liberia, Sierra Leone and Sudan. Prevalence varies eg in Sierra Leone, approximately 90% of girls are circumcised as part of their initiation into womanhood. Not practiced in Rwanda and Burundi • women may be unwilling to discuss; there is a spectrum of opinions and attitudes regarding FGM within African communities. It is important to approach discussion in general and non-judgemental ways • complications can include vulval scarring and pain, chronic pelvic pain, urinary tract infections, incontinence, obstructed menstrual and urinary flow, obstructed miscarriage and childbirth, vaginal and perineal damage during delivery, difficulties and pain with sexual intercourse • Australia is committed to prevention through education and legislation. Information, referral, support and advice available through Family and Reproductive Rights Education Program (FARREP) (see referral information) Compliance • women are more likely to suffer high rates of illiteracy and lack confidence in dealing with authority which may affect their ability to understand questions and disclose relevant information • informed consent: in the medical context this requires an understanding of decisions made in relation to health matters. This impacts on medical advice, referrals, prescriptions etc. Language and cultural barriers, as well as unfamiliarity with western health systems and procedures can make many tasks seem complex, even distressing for the client eg filling a prescription, arranging an X-ray • the lack of interpreter resources for people from new emerging African communities may affect compliance • in some circumstances refugee women may continue to suffer domestic violence in Australia -  - Investigative and Procedural Implications Identifying Survivors of Sexual Violence • women will rarely identify themselves as a survivor of sexual trauma • information about the country of origin and general queries about the time and circumstances of departure, life as a refugee and the journey to Australia, will help to establish the likelihood of exposure to sexual trauma • general questions that convey sensitivity and understanding may also be helpful, eg Terrible things have happened to many women who have been forced to leave your country. Have you had any terrible experiences that are causing you pain or affecting your health now? Variation of responses • different cultures, experiences and understandings naturally mean there is variation among women in their responses and their willingness to talk about sexual health, gynaecological issues, STI’s and FGM. What is taboo for some, may not be for others. It may be helpful not to refer directly to specific conditions but ask generally about sexual and reproductive health • a gradual approach to assessment and management will help build rapport and trust Support and Familiarity with Health Services • allow adequate time, women are generally unfamiliar with our health care system and services, including appointment systems, referrals and Medicare • many women have never had a breast examination, a pap smear or an internal examination • important to ask about complementary or traditional therapies as well as medication prescribed by other healthcare practitioners • be aware that patients may be concerned that their traditional health beliefs may be dismissed as superstitious • help to facilitate appropriate support structures that link women with services, resources and networks to support them • consider use of specifically developed patient education materials which explain diseases, investigations and procedures in community languages (see referral information) Gender of Practitioner • male practitioners should consider offering female clients referral to an experienced female practitioner or gynaecologist, particularly if investigation or treatment of gynaecological problems is required for general medical care Potential Investigations • STI’s – consider non-invasive procedures eg first pass urine for Chlamydia and Gonorrhoea; blood tests for HIV, Hep B, Hep C and Syphilis • pap smear examination: allow adequate time and a sensitive and empathic approach. If patient has had FGM, the use of small speculum may be necessary or referral to a practitioner experienced in this situation • breast examination: may be unfamiliar and require explanation • mammography: consider use of BreastScreen which employs female ultrasonographers • pelvic ultrasounds: a transvaginal pelvic ultrasound will require much explanation and use of a female technician where possible Torture and Trauma • physical examination and other aspects of the consultation may be reminders of past torture and trauma. Consider this when planning specialist medical, surgical or gynaecological referral • physical symptoms, eg muscular and joint pains may be somatic expressions of torture and trauma Interpreters

• whenever possible use onsite female interpreters to optimize communication, build rapport and reduce anxiety • it may be difficult to arrange interpreters in the preferred language of some newly-arrived refugees from African countries • reliance on family members may compromise privacy and discourage disclosure Referral • facilitate referral by including relevant information of client’s refugee experiences • refer where possible to services offering female practitioners and interpreters • consider practical difficulties including financial cost, transport and childcare • consider consultation with, or referral to, specialist agency and/or resources (see referral information)

“... there is an opportunity to build dignity with every human encounter. Given that it is the human hand that has perpetrated violations it is the human hand that has the power to heal wounds. The quality of relationships can however, be undermined

when workers face the sheer immensity of needs. To deal with being potentially overwhelmed, overly distant styles of

working can occur, whereby women’s problems are minimized or overlooked. Alternatively, some workers respond with ‘rescuing’ that diminishes the power of women. Awareness of such responses and the implications for ways of working “ require sufficient levels of support and professional development.

Kaplan I and Webster K “Refugee Women and Settlement: Gender and Mental Health” Allotey P (ed) (2003) The Health of Refugees: Public Health Perspectives from Crisis to Settlement, Oxford University Press, UK

-  - The Victorian Foundation for Survivors of Torture (VFST) provides direct care to survivors of torture and trauma in the form of counselling, advocacy, family support, group work, psycho-education, information sessions and complementary therapies. The VFST also plays an important developmental role with service providers through training, consultancy, research and capacity-building.

The following information was compiled to help build an understanding among service providers of the needs of refugee women who have suffered sexual violence. For further information and referral, a select list of agencies and resources is provided below.

Specialist Referral (Victoria) and Resources:

Medical Services Melbourne Sexual Health Centre http://www.mshc.org.au/index.cfm The Royal Australian College of General Practitioners (RACGP)http://www.racgp.org.au/refugeehealth/ The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG 2004) Medical responses to adults who have experienced sexual assault: an interactive educational module for doctors. Information and an order form available at http://www.ranzcog.edu.au/sexual-assault-module. shtml The Royal Children’s Hospital Immigrant Child Healthhttp://www.rch.org.au/paed_handbook/cph/index.cfm?doc_id=250 2 BreastScreen Victoria http://www.breastscreen.org.au/

FGM Family And Reproductive Rights Education Program (FARREP): Royal Women’s Hospital Ph: 03 9344 2211 Mercy Hospital for Women Ph: 03 9270 2222 Monash Medical Centre Ph: 03 9594 6666 DHS Victorian Government Health Information website FARREP http://www.health.vic.gov.au/vwhp/farrep.htm Clinical Practice Guidelines can be accessed on: http://www.rwh.org.au/rwhcpg/womenshealth.cfm?doc_id=4343 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG 1997) Female Genital Mutilation: Information for Australian Health Professionals http://www.ranzcog.edu.au/publications/pdfs/FGM-booklet-sept2001.pdf Australian Institute of Family Studies FGM Bibliography http://www.aifs.gov.au/nch/bib/fgm.html

Psychosocial and Psychological Care Victorian Foundation for Survivors of Torture (VFST) Ph: 03 9388 0022 http://www.survivorsvic.org.au/ Centre Against Sexual Assault (CASA) Ph: 1800 806 292 http://www.casa.org.au/index.php/1 Victorian Immigrant and Refugee Women’s Coalition (VIRWC) http://www.virwc.org.au/ Immigrant Women’s Domestic Violence Service http://www.iwdvs.org.au/home.htm Ph: 03 9898 3145

Resources for Clients and Workers DHS Community Language Health Information & Resources: http://www.healthtranslations.vic.gov.au/ Royal Womens Hospital Well Womens Website On Line Fact Sheets in community languages: http://www.rwh.org.au/wellwomens/whic.cfm?doc_id=2422 BreastScreen Victoria translated publications http://www.breastscreen.org.au/ Working Women’s Health 03 9482 3299 http://www.workingwomenshealth.asn.au/

Background Information Amnesty International (2004) Its In Our Hands: Stop Violence Against Women http://web.amnesty.org/library/pdf/ACT770032004ENGLISH/$File/ ACT7700304.pdf Giles W & Hyndman J (eds) (2004) Sites of Violence : Gender and Conflict Zones. University of California Press, Berkeley. Hill P, Lipson J, Meleis A I (2003) Caring for Women Cross-Culturally F.A. Davis Company, Philadelphia. Human Rights Watch (2000) Seeking Protection : Addressing Sexual and Domestic Violence in Tanzania’s Refugee Camps http://www.hrw.org/reports/2000/ tanzania/ Human Rights Watch (2005) Seeking Justice: The Prosecution of Sexual Violence in the Congo War http://hrw.org/reports/2005/drc0305/ IRIN (2004) Our Bodies -Their Battleground: Gender-based Violence in Conflict Zones http://www.irinnews.org/webspecials/GBV/gbv-webspecial.PDF Kemp C & Rasbridge L, (2004) Refugee and Immigrant Health: A Handbook for Health Professionals. Cambridge University Press, Cambridge. Also see associated website: Refugee Health Immigrant Health website: http://www3.baylor.edu/~Charles_Kemp/refugees.htm UNHCR (2003) Sexual and Gender- Based Violence against Refugees, Returnees and Internally Displaced Persons: Guidelines for Prevention and Response http:// www.rhrc.org/pdf/gl_sgbv03_00.pdf UNICEF (2005) The Impact of Conflict On Women and Girls In West and Central Africa And The UNICEF Response http://www.unicef.org/publications/files/ Impact_final.pdf UNIFEM Women War Peace http://www.womenwarpeace.org/ WHO (2005 revised edn) Clinical Management of Survivors of Rape: Developing protocols for use with refugees and internally displaced persons. http:// www.who.int/reproductive-health/publications/rhr_02_8_clinical_management_survivors_of_rape/ Women’s Commission for Refugee Women and Children http://www.womenscommission.org/

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